The document discusses the prone position as a rescue therapy for severe Acute Respiratory Distress Syndrome (ARDS), characterized by acute lung inflammation and impaired oxygenation. It outlines the stages and severity classification of ARDS, treatment approaches, indications and contraindications for prone positioning, and its benefits for improving lung function and oxygenation. Current research supports its use within the first 48 hours of ARDS onset, with recommended durations of 12-24 hours for optimal effectiveness.

1. PRONE POSITION
RESCUE THEAPY FOR SEVERE ARDS

2. PRONE POSITION
Acute Respiratory Distress Syndrome (ARDS) is
defined as a:
“syndrome of acute and persistent lung
inflammation with increased vascular
permeability” (Hansen-Fletcher et al)

3. PRONE POSITION
Clinically, ARDS is
characterized by:
• acute onset (< 48
hours)
• bilateral infiltrates
• PaO2/FiO2 ratio
<300mmHg
• No evidence of
cardiac causes

4. PRONE POSITION
• ARDS is classified by its cause:
– Direct lung injury: pneumonia, aspiration,
inhalation injuries, ect..
– Indirect lung injury: sepsis, OD, massive blood
transfusions, ect..
• Its severity (PaO2/Fio2 ratio):
– mild (200-300 mmHg)
– moderate (100-200 mmHg)
– severe (<100mmHg)

5. PRONE POSITION
Recovery
Stage
•Slow restoration of lung
function
Proliferative
Stage
•7—21 days
•Alteration of lung tissue
•Poor Compliance
•Decreased Edema
Exudative
Stage
•0-7 days
•Edema (peaks 048hrs)
•Inflammation
Typically, lung dysfunction is the worst during the first 0-48hours and
may last for up to a week.

6. PRONE POSITION
Treatment of ARDS:
• Treat underlying cause (i.e. sepsis)
• Lung protective ventilation (low Vt +
adequate PEEP)
• Avoid a positive fluid balance
However, in severe cases of ARDS (low pH, O2
and high CO2 and airway pressure) standard
therapy main fail.
Rescue therapy may be needed: prone position
Prone
Position
ECMO

7. PRONE POSITION
Indications for the prone position:
Capital Health Prone Criteria:
• ARDS
• < 48 hours
• Pa02/FiO2 <200mmHg

8. PRONE POSITION
Relative contraindications for the prone position:
• Elevated ICP
• Intestinal ischemia
• Obesity
• Recent Abdominal Surgery
Absolute contraindications for the prone position:
• spinal cord instability,
• unstable facial fractures
• anterior burns, open abdomen
• increased abdominal pressures
• unstable pelvic fractures.

9. PRONE POSITION
The Prone Position:
• Improves perfusion to the lungs → Better V:Q matching
• The diaphragm drops and the heart shift forward → Improved compliance
• Improved lung recruitment
• Lung Protective
• Indicated:
• Moderate to Severe ARDS
• Early (<48hours)
• Duration: 12 – 16 hours

10. PRONE POSITION
• In healthy lungs the
distribution of perfusion
is effected by gravity.
• The apex and the middle
of the gets more
ventilation (V) than
perfusion(Q). V>Q
• At the base, the lungs get
more perfusion (Q) than
ventilation (V). V<Q
• Atelectasis and
inflammation of the lungs
leads to worsening V:Q
matching

11. PRONE POSITION
Perfusion (Q) of the
anterior and base of the
lungs improves in the
prone position.
• The improved V:Q matching
may improve oxygenation.

12. PRONE POSITION
The diaphragm drops and the heart shift forward → Improved compliance
May lower airway pressure
May improve VT and MV (↓CO2)
May reduce lung protective (↓ atelectotrauma, barotrauma & volutrauma)

13. PRONE POSITION
NURSING CARE:
• Ensure adequate sedation and analgesia (meet
goal RASS)
• Ensure adequate paralysis (meet TOF goal)
• ABG PRN to assess oxygenation (PaO2) &
ventilation (PaCo2)
• Reposition arms Q2H (see prone policy)
• Check Q2H for pressure areas
• Family education

14. PRONE POSITION
IN CONCLUSION:
• Current research (PROSEVA) demonstrates
that the prone position is may be beneficial
in severe ARDS (<48 hours).
• Duration 16-24 hours
• Inexpensive compared and easy to perform
• May be lung protective (improve
compliance)
• May improve oxygen and ventilation (better
V:Q matching)

15. PRONE POSITION
THANK YOU!